Consolata Rehab And Wellness Center On The Teche

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that resident or resident's RP (Responsible Party) were invited to, attended, or participated in quarterly care plan meetings for 1 (Resident #47) resident out of 28 sampled residents. Findings: Review of facility document titled admission Agreement, dated 01/15/2025 revealed in part, family members are encouraged to visit often and participate in the resident's plan of care. Each quarter the Responsible Party will be invited to attend the resident's care plan conference. Review of Resident # 47's admission Record revealed she was admitted to the facility on [DATE] and had diagnoses which included, but were not limited to, congestive heart failure, dementia and cognitive communication deficit. Review of Resident #47's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 03/13/2025 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 2, indicating Resident #47's cognition was severely impaired. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, and maintenance log review, the facility failed to provide a homelike environment, by failing to address a concern regarding bed repairs for 1 (#11) of 4 (#11, #13, #27, and #260) residents investigated for environment. Findings: On 04/01/2025, a review of the facility's policy titled Resident equipment with a reviewed date of 01/14/2025, read in part, Purpose: The purpose of this policy is to ensure resident equipment is properly maintained. Procedures .2. Maintenance director will assess any repairs needed and will report any equipment that is inoperable to the nursing facility administrator. On 03/31/2025 at 10:30 a.m., an observation was made of Resident #11 in her room. She stated the button on the head of her bed had not been working for over 2 months, and she had reported it to maintenance. She stated she could not lower or lift her head making it uncomfortable to sleep. During an interview on 03/31/2025 at 10:30 a.m., S9CNA Certified Nursing Assistant), stated she worked two weeks ago and the remote wasn't picking the resident's head up and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the resident's status, for 1(#7) of 28 sampled residents. Findings: A review of Resident #7's medical records revealed an admission date of 02/14/2024 with diagnoses which included but were not limited to schizoaffective disorder. A review of Resident #7's Pre admission Screening and Assessment Resident Review (PASRR) revealed a Level 11 determination that read, The individual has a serious mental illness . A review of Resident #7's annual MDS with an Assessment Reference date of 02/12/2025, revealed the following in section A1500: Is the resident currently considered by the state level 11 PASRR process to have serious mental illness and/or intellectual disability or a related condition? The answer was coded 0 for no. On 04/02/2025 at 1:37 p.m., an interview and review of Resident #7's MDS was conducted with S4MDS/LPN (Minimum Data Set/Licensed Practical Nurse). She confirmed that the PASRR was incorrectly coded and did not reflect that the resident was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that a resident received services according to the person-centered plan of care for 1 (#14) of 28 sampled residents. Findings: Review of Resident #14's Electronic Health Record (EHR) revealed the resident was admitted to the facility on [DATE] with diagnoses which included but were not limited to Asthma, acute respiratory failure with hypoxia, acute ischemic heart disease, obstructive sleep apnea and chronic systolic (congestive) heart failure. Review of Resident #14's care plan revealed a focus area indicating the resident was at risk for falls, r/t (related to) decrease mobility, depression, respiratory failure and history of falls. Interventions included in part, refer to therapy dept (department) as needed, and refer to restorative program as needed . Review of S19PT (Physical Therapy) notes revealed Resident #14's discharge summary for dates of services 02/28/2024- 03/08/2024 with discharge reason maximum Potential achieved. Referred for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming by failing to trim and clean a resident's fingernails for 1 (Resident #39) of 28 sampled residents. The deficient practice had the potential to affect a census of 60. Findings: A review of the facility's policy titled, Care of Fingernails/Toenails with a last review date of 02/03/2025, read in part, The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. The policy also indicated general guidelines, Nail care includes daily cleaning and regular trimming. A review of Resident #39's electronic medical record revealed he was admitted to the facility on [DATE] with diagnoses that included in part, Type 2 Diabetes Mellitus without Complications and Vitamin D Deficiency. A review of Resident #39's Annual MDS (Minimum Data Set) dated 02/25/2025 revealed he had a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to ensure a resident received enteral feedings as ordered by the physician for 1 (Resident #51) out of 28 sampled residents. Findings: Review of Resident #51's admission Record revealed she was admitted to the facility on [DATE] and had diagnoses which included, but were not limited to, dysphagia, adult failure to thrive, and cachexia. Review of Resident #51's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 03/20/2025 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 0, which indicated the resident had a severe cognitive impairment. Further review revealed in Section K: Swallowing/Nutritional Status Resident #51 had a feeding tube. Review of Resident #51's Order Summary Report revealed an order dated 03/27/2025 that read: Enteral feed order every shift, Jevity 1.2 70 ml/hr (milliliters per hour) with water flushes of 100 ml (milliliters) every four hours free flushes with pump. Review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that a resident receiving dialysis received services consistent with professional standards of practice and the comprehensive person-centered care plan for 1 (#260) of 1 (#260) resident receiving dialysis out of a total sample size of 28 residents. Findings: On 04/02/2025, a review of the facility's policy titled Weight Assessment and Intervention with a last reviewed date of 01/15/2025, read in part, Policy statement: Resident weights are monitored for undesirable or unintended weight loss or gain: Policy Interpretation and implementation: Weight assessment: 1. Residents are weighed upon admission and at intervals established by the interdisciplinary team or the resident's physician. Resident #260 was admitted on [DATE] with diagnoses which included but were not limited to end stage renal dialysis and dependence on renal dialysis. A review of Resident #260's physician's orders revealed an order written on 03/20/2025 which read, Weights - Daily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, and interviews, the facility failed to ensure: 1. Resident #2 and Resident #3 were assessed for the risk of entrapment from side rails. 2. Informed consent was obtained from the resident or resident's representative prior to installation of side rails for Resident #2 and Resident #3. 3. Ongoing monitoring and supervision were provided for Resident #2's use of side rails. This deficient practice occurred for 2 (Resident #2, and Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. Findings: Review of the facility's policy, Physical Restraints, Side Rails, with a last review date of 01/15/2024, revealed in part: Purpose: The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. General Guidelines: 3. An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure all allegations of injuries of unknown source that resulted in serious bodily injury was reported immediately, or within 2 hours of the allegation to the state survey agency for 1 (#1) out of 2 (#1 and #2) residents sampled with incidents. Findings: On 11/25/2024, a review of the facility's policy titled, Abuse Investigation and Reporting with a last revision date of 01/15/2024, read in part, Reporting: 1. All alleged violations involving abuse, neglect exploitation, or mistreatment, including injuries of unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; The policy also indicated that the following information 2. An alleged violation of abuse, neflect, exploitation or mistreatment (including injuries of unknown source and misappropriation of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record reviews and interviews, the facility failed to develop and implement a person centered care plan for 1(Resident #2) out of 3 (Resident#1, Resident #2, and Resident #3) sampled residents by failing to ensure that the use of side rails was included in the Plan of Care for Resident #2. Findings: A review of the facility's policy Physical Restraints, Side Rails, with a last review date of 01/15/2024, revealed in part: Purpose: The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. General Guidelines: 4.The use of side rails as an assistive device will be addressed in the resident care plan. Review of Resident #2's medical record revealed an admission date of 8/16/2023 with diagnosis including, but were not limited to, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Bipolar Disorder, and Major Depressive Disorder. Review of Resident #2's Plan of Care contained no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to maintain accurate medical records in accordance with accepted professional standards and practices for 1 (#1) out of 3 (#1, #2, and #3) sampled residents by failing to ensure the EMAR (Electronic Medication Administration Record) was complete and/or accurately documented for Resident #1. On 11/25/2024, a review of the facility's policy titled, Charting and Documentation with a last revision date of 01/15/2024, read in part, Policy Statement: All services provided to the resident, progress toward the care plan goals, or any change in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The policy also indicated that the following information is to be documented in the resident medical record: Medication administered, treatments or services performed, events, incidents or accidents involving the resident and progress toward or changed in the care plan goals and objectives. Review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure that nurse aides are able to demonstrate competency in skills necessary to care for residents' needs, as identified through observation of pleasure feedings for 1 (#3) of 4 (#1, #2, #3, R1) sampled residents. Findings: Review of Resident #3's clinical record revealed an admit date of 08/01/2023, with diagnoses which included Malnutrition, Vitamin D Deficiency, Type 2 Diabetes, Chronic Kidney Disease. Resident#3 received continuous PEG (Percutaneous endoscopic Gastrostomy) tube feedings with pleasure feedings. A further review of Resident #3's clinical record revealed a Speech Therapy Discharge summary dated [DATE] that read in part . Requires cueing to utilize strategy. The summary included interventions provided: swallow treatment facilitation of liquid delivery using small controlled sips/intake, facilitation of small bites/sips (1/2 to 1/3 tsp), facilitation of body positioning to increase safety with intake, training in use of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews and record review, the facility failed to ensure 1 (#1) of 3 (#1, #2, and #3) sampled residents was safe to perform self-administration of medication. The right to self-administer medications is the responsibility of the interdisciplinary team to assess and determine if this practice is clinically appropriate and safe. Findings: On 11/13/2024 a review of the facility's undated policy titled Self-Administration of Medications, read in part, Policy Statement: Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. Review of Resident #1's electronic health record revealed an admission date of 02/27/2024 with Diagnoses which included, but were not limited to Urinary Tract Infection,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, and interview, the facility failed to promote and facilitate resident self-determination through support of resident choice about aspects of his or her life in the facility that were significant to the resident for 1 (#2) of 3 sampled residents. The facility failed to accommodate Resident #2's choice to refuse care. Findings: Review of the facility's policy titled Residents' Rights with a review date of 01/22/2024 read in part .Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: B. be treated with respect, kindness, and dignity H. be supported by the facility in exercising his or her rights. Review of Resident #2's clinical record revealed an admit date of 05/09/2024 with diagnoses that included: Chronic Obstructive Pulmonary Disease (COPD), Coronary Artery Disease, Heart Failure, Peripheral Vascular Disease, Cerebrovascular Accident, and Depression. Review of Resident #2's Quarterly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to maintain privacy and confidentiality of residents' medical records for 1 (#R1) out of 4 sampled residents. The facility had a total census of 61 residents. Findings: Review of the facility's document titled, Resident Rights with a review date of 01/22/2024, and read in part .Policy Interpretation and Implementation: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: T. privacy and confidentiality. Review of the facility's document titled Security of Medication Cart with a review date of 01/15/2024, read in part the nurse must initiate the computer privacy screen when the computer is out of the nurse's view. On 11/13/2024 at 8:00 a.m., an observation of the dining room area was conducted. Further observation revealed that Medication Cart B was parked outside the dining room area. The medication cart was observed unattended and unlocked with #R1's personal information being visible for visitors/residents in the facility. On 11/13/2024 at 8:01…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's person centered care plan was reviewed and revised by the interdisciplinary team after each assessment for 1(#1) of 3 (#1, #2, and #3) sampled residents as evidenced by Resident #1's care plan not reflecting the resident's wish to transfer to another facility. Findings: Review of Resident #1's Electronic Health Record revealed she was admitted to the facility on [DATE] with Diagnoses which included, but were not limited to Urinary Tract Infection, Chronic Kidney Disease, Schizophrenia, and Bipolar Disorder. Review of Resident #1's 5 day MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/28/2024 revealed in Section Q, Participation in Assessment and Goal Setting, that her goal was to remain in the facility. Review of Resident #1's current care plan revealed an entry with onset date of 02/27/2024, I wish to remain in facility/No plans to D/C (discharge) at this time. Review of a grievance dated 10/01/2024 revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview the facility failed to ensure medication Carts were locked when unattended for 2 (Cart A, Cart B) of 3 (Cart A, Cart B, Cart C) medication carts observed. Findings: Review of the facility's document titled Security of Medication Cart with a review date of 01/15/2024, read in part when the medication cart is not being used, it must be locked and parked at the nurses station or inside the medication room. On 11/12/2024 at 3:00 p.m., an observation of on Hall A was conducted. Further observation revealed Medication Cart A was unlocked and unattended. S4LPN (Licensed Practical Nurse) was observed sitting in the nurses station talking on her cell phone. On 11/12/2024 at 3:01 p.m., an interview was conducted with S4LPN. S4LPN confirmed that she should have locked her medication cart prior to leaving the cart unattended. On 11/12/2024 at 3:40 p.m., an observation of Hall B was conducted. Further observation revealed Medication Cart B was against the wall near the nurse's station, unattended and unlocked. A visitor was observed in the hallway near the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and observations, the facility failed to ensure the residents call system was functioning for 1 (#1) out of 3 (#1, #2, #3) sampled residents. Findings: On 07/09/2024, a review of the facility's policy titled, Answering the Call Light, with review date of 01/01/2024, revealed in part: Purpose: the purpose of this procedure is to ensure timely responses to the resident's requests and needs. General Guidelines .4. Be sure that the call light is plugged in and functioning at all times .6. Report all defective call lights to the nurse supervisor promptly. Review of Resident #1's record revealed he was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Chronic Systolic Heart Failure, Chronic Venous Insufficiency, Chronic Kidney Disease Stage 3, and Type 2 Diabetes Mellitus. A review of Resident #1's MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 06/15/2024, revealed Resident #1 had a BIMS (Brief Interview of Mental Status) score…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that a resident's physician was consulted when there was a change in the plan of care for 1(#1) of 3 (#1, #2, and #3) sampled residents. The facility failed to notify Resident #1's physician that his smoking privileges were revoked, and that staff were administering a nicotine replacement that had not been ordered by a physician. This deficient practice had the potential to affect the 9 residents who smoked. Findings: Resident #1 was admitted to the facility on [DATE], with diagnoses which included, but were not limited to Anxiety disorder, Major depressive disorder, Quadriplegia and Mood disorder. A review of the Resident's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 04/29/2024 revealed in section C that he had a BIMS (Brief Interview for Mental Status) score of 14, indicating his cognition was intact. Section GG revealed the resident was impaired on both sides and was dependent on staff for eating, care, and transfer. A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interview, the facility failed to ensure that a resident with a qualifying mental disorder, was not admitted to the facility before a preadmission screening by the State Office of Behavioral Health (OBH) was completed or obtained for 1 (#1) of 3 (#1, #2, and #3) sampled residents investigated for a complaint. Findings: On 06/06/2024, a review of the facility's policy titled PASRR (Pre-admission Screening and Resident Review) with a revision date of 12/10/2020, read in part, Purpose: The purpose of this policy is to ensure facility is following state guidelines regarding PASRR. Resident #1 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to Anxiety Disorder, Unspecified Mood Disorder, and Major Depressive Disorder. A review of the resident's clinical records revealed a level 1 PASRR dated 08/17/2023. In Section 111: Mental illness, an answer of no was selected for suspected or diagnosed mental illness. Further review revealed no level 2 PASRR.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the facility's policy and procedure, and interviews, the facility failed to develop a comprehensive person-centered care plan within 7 days of the completion of the required comprehensive assessment MDS (Minimum Data Set) for 5 (Resident #4, 12, 16, 21, and 31) out of 5 (Resident #4, 12, 16, 21, and 31). The final sample size was 31. Findings: Resident #4 Review of Resident #4's record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Hepatitis A Without Hepatic Coma, Type 2 Diabetes Mellitus, Chronic Atrial Fibrillation, and Chronic Obstructive Pulmonary Disease. Review of Resident #4's Annual MDS with an ARD (Assessment Reference Data) of 03/05/2024. Further review of Resident #4's EHR (Electronic Health Record) failed to reveal a compressive person-centered care plan. Resident #12 Review of Resident #12's record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews the facility failed to properly store and label respiratory equipment for 2 (#9 and #16) out of 2 (#9 and #16) residents investigated for respiratory care. Findings: On 04/02/2024, a review of the facility's policy, Oxygen Administration, with a last reviewed date of 01/05/2024, revealed in part, the following, Policy: . All safety precautions and care of equipment shall be performed accord to recommended State and Federal guidelines and facility procedures. Prefilled humidifier bottles and nasal cannulas/mask will be changed every week and prn (as needed). All tubing and bottles are to be labeled each week when changed. When the tubing is not being used, it should be stored properly in a zip lock bag . Essential Points: There are multiple state and federal codes that address the storage, handling, and administration of oxygen. Procedures must be adhered to assure compliance with these codes . Resident #9 Review of Resident #9's health record revealed that he…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observations and record review the facility failed to ensure that pharmaceutical services provided to meet the needs of each resident were consistent with state and federal requirements and reflect current standards of practice as evidenced by: 1. Failing to ensure medication was not left at Resident #31's bedside; 2. Failing to ensure medications were not left unattended on top of the medication cart; 3. Failing to ensure controlled medication was not taped back in the blister pack; 4. Failing to ensure medications were stored separately from food and labeled with the resident's name. Findings: On 04/02/2024, a review of the facility's policy, Medications Storage, with a last reviewed date of 01/05/2024, revealed in part, the following, Policy Statement: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation: . 2. The nursing staff shall be responsible for maintaining medication storage . 9. Medications must be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a homelike environment for 1 (#30) out of 2(#17, #30) residents investigated for environment, out of a total sample of 31 residents. Findings: Resident #30 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Acute Embolism and Thrombosis of Unspecified Deep Veins of Left Lower Extremity, and Moderate Protein Calorie Malnutrition. On 04/01/2024 at 9:15 a.m., an observation was made of Resident #30's bathroom. A copper colored stain was observed from the base of the left faucet into the left side of the bathroom sink. There was also a copper colored stain around the knob on the right base of the toilet spreading outward, and a large paint blister on the wall on the left side of the toilet. Further observation revealed a moderate build-up of dust on the vent in the ceiling of the bathroom. On 04/02/2024 at 3:31 p.m., a second observation was made of the resident's bathroom. The copper colored stains remained…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to develop a comprehensive plan of care for 2 (#13 and #17) out of 3 (#13, #15, #17) residents investigated for care planning out of a total sample of 31 residents, by failing to: 1. Address Resident #13 family's refusal for use of a proper positioning device. 2. Address Resident #17's limited range of motion. Findings: Resident #13. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnosis included Alzheimer's disease. Review of the resident's care plan revealed the resident used a wheelchair for mobility. On 04/01/24 9:45 a.m., the resident was observed slouched down in her high back wheelchair in the dining room. On 04/01/2024 at 11:57 a.m., S10CNA (Certified Nursing Assistant) began feeding the resident lunch at the dining room table. The resident was observed slouched down in her high back wheelchair while the CNA was feeding the resident. On 04/02/2024…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure each resident with pressure ulcers received the necessary treatment and services to promote healing as evidenced by the staff failing to assess and provide treatment for an identified pressure ulcer for 1 (#13) out of 31 sampled residents. Findings: Resident #13. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnosis included Alzheimer's Disease. Review of the resident's Braden Risk assessment dated [DATE] revealed the resident was assessed as a high risk for pressure ulcer development. Review of the resident's weekly skin inspection on 01/15/2024 revealed the resident's skin was intact. Review of the resident's weekly skin inspection on 01/22/2024 revealed the resident's skin was not intact. Review of the resident's electronic clinical record revealed that there was no evidence that an assessment of a pressure ulcer or wound was done on 01/22/2024. Review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure each resident receives adequate supervision and assistance to prevent falls for 1 (#42) out of 2 (#40, #42) sampled residents investigated for falls out of a total sample of 31 residents. Findings: Resident #42. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnosis included Unspecified Dementia with other Behavioral Disturbance. Review of the resident's quarterly MDS (Minimum Data Set) dated 01/31/2024 revealed the resident's BIMS (Brief Interview Mental Status) score was 3 for severely impaired for cognition. Also, the quarterly MDS revealed the resident was coded for bed and chair alarm daily. Review of the resident's care plan revealed that it addressed falls. Bed and chair alarms were both interventions to prevent falls. On 04/02/2024 at 2:00 p.m., the resident was observed sitting up in wheelchair at dining room table. The resident was observed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that medications and pharmaceutical services were provided to meet the needs of 2 (#25, #31) out of a total sample of 31 residents, by failing to: 1. Ensure that Resident #25's Plavix (blood thinner) was re-ordered and administered; 2. Maintain a system to account for the usage and reconciliation of all controlled medications. Findings: On 04/03/2024 at 10:30 a.m., a review of a policy titled Pharmacy Services-Ordering Medications with a revision date of 01/05/2024, revealed in part, Purpose: To ensure all medications are ordered in a timely manner. Policy .3. Drugs and Biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than five days prior to the last dosage being administered to ensure that refills are readily available. 1. Review of Resident #25's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses including, but were not limited to,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to maintain an effective infection control and prevention program by failing to perform hand hygiene before preparing medications and after removing gloves after patient contact. This deficient practice had the potential to affect the 70 residents residing in the facility. Findings: On 04/03/2024, a review of the facility's policy titled Handwashing/Hand Hygiene with a revision date of 01/05/2024, revealed in part, Policy Statement. This facility considers hand hygiene the primary means to prevent the spread of infections .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections .7 .b. Before and after direct contact with residents; c. Before preparing or handling medications .m. after removing gloves. On 04/02/2024 at 7:52 a.m., S14LPN (Licensed Practical Nurse) was observed during D1. She donned a pair of gloves, drew up insulin and walked into Resident #25's room to administer the medication. S14LPN returned to the cart, removed her gloves and did not perform hand…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews, the facility failed to maintain an effective infection control and prevention program and implement accepted infection control practices to help prevent and/or contain the spread of infectious communicable disease, COVID-19, as evidenced by failing to: 1. ensure staff wore masks that covered their mouth and nose while the facility was in outbreak status and prior to entering isolation rooms; 2. appropriately discard used PPE (personal protective equipment) after exiting a COVID-19 isolation room; 3. properly handle and transport contaminated linens; 4. use nationally recognized surveillance criteria to define infections; 5. ensure contracted hospice personnel did not place potentially contaminated items on a resident's bed; 6. ensure staff put on PPE when entering an isolation room for terminal cleaning; and 7. perform hand hygiene when indicated during wound care for Resident #14. The facility had a census of 57 residents. Findings: Review of the facility's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, policy review, and interviews, the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility initiated discharges for 1 (#1) of 1 (#1) residents investigated for hospitalization. The deficient practice had the potential to affect a total census of 57 residents. Findings: A review of the policy titled Transfer or Discharge Notice revealed the following in part: 4. A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman. A review of the record revealed that Resident #1 admitted to the facility on [DATE] with diagnoses that included Quadraplegia, Neurogenic Bladder and Bowel, Chronic Urinary Tract Infections. A review of Resident #1's clinical record revealed a Physician's order dated for 02/14/2023 that read Send to emergency room upon family request. A review of Resident #1's clinical record included a hospital Discharge Summary report that revealed Resident #1 had been admitted to the hospital on [DATE]. Further review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to have an RN (Registered Nurse) conduct/coordinate each assessment with other health care professionals; certify that assessments are complete; sign and certify the accuracy of the assessment for 6 (Resident #8, Resident #19, Resident #22, Resident #23, Resident #31, and Resident #308) residents of 32 total sampled residents. Findings: Review of the facility's policy titled MDS (Minimum Data Set) Policy and Procedure read in part .8. Compliance: The policy should stress the importance of complying with all relevant laws, regulations and organizational policies related to the Minimum Data Set and patient care. Review of Resident #8's MDS with an ARD(Assessment Reference Date) of 01/12/2023, revealed a status of Accepted , indicating that the Resident's assessment was completed and signed by an RN. Further review of Resident #8's MDS assessment revealed section Z500-Signature of RN Assessment, was completed and signed by an LPN (Licensed Practical Nurse). Review of Resident #19's MDS with ARD of 12/15/2022, revealed a status…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to store food in accordance with professional standards for food service by failing to: 1. Remove scoops from dried food storage bins 2. Ensure an expired food item was removed from the dry goods storage room 3. Ensure an opened and used food item was labeled with the date and time. This deficient practice had the potential to affect 40 residents who consumed meals and/or beverages prepared and/or served from the facility's kitchen. Findings: Review of the facility's policy titled Food Receiving and Storage read in part .7. Dry goods that are stored in bins will be removed from original packaging, labeled and dated. On 03/20/2023 at 9:30 a.m., the following observations of the facility's kitchen were conducted with S4DS (Dietary Supervisor): An observation was made of the food preparation counter. There were 2 bins on the preparation counter, one with flour, and another with powdered cream potatoes. Both bins contained 1 cup scoops. S4DS confirmed that the scoops were in the bins and should not have been. An…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents received necessary treatment and services consistent with professional standards of practice and to promote healing for 1 (#45) of 3 (#1, #14, #45) sampled residents. The facility had 4 residents with pressure ulcers. Findings: Review of Resident #45's medical record revealed he was admitted to the facility on [DATE] and had diagnoses that included, in part, Chronic Kidney Disease, Creutzfeldt-[NAME] Disease, and Left Heel Unstageable Pressure Ulcer Review of Resident #45's March 2023 physician orders revealed the following orders: -An order dated 01/24/2023 for Wound care to left heel: clean area with wound cleanser and pat dry. Apply medihoney to wound bed, cover with calcium alginate, secure with covering dressing daily. Review of Resident #45's Weekly Wound Assessment reports indicated his wounds were measured in centimeters and presented in length x width x depth. Resident #45's Weekly Wound Assessments revealed only the following…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record reviews, the facility failed to ensure there was adequate supervision and monitoring for 1 (#40) of 3 (#9, #40, #45) residents who were reviewed for falls. Findings: Resident #40 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, Dementia with Other Behavioral Disturbances and Anxiety. Review of Resident #40's quarterly MDS (Minimum Data Set) dated 02/13/2023 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 07, which suggested severe cognitive impairment. Review of Resident #40's physician orders dated 03/2023 read in part, an order entry dated 01/31/2023: close monitoring every 1 hour for 7 days, then reevaluate. Review of a document titled Close Monitoring revealed that close monitoring was initiated on 01/31/2023 at 3:00 p.m. Further review revealed that on 02/01/2023 monitoring was not completed from 7:00 a.m. - 2:00 p.m. and from 5:00 p.m. to 10:00 p.m. On 02/02/2023, there was no documented monitoring from 5:00…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure respiratory equipment was properly stored when not in use for 1(#38) out of 1 residents investigated for respiratory care out of a total sample of 32 residents. Findings: Review of the facility's policy titled Oxygen Administration read in part: .When .CPAP (Continuous Positive Airway Pressure) masks, are not in use, they should be stored in plastic bags. Resident #38 was admitted to the facility on [DATE] with diagnoses in part: Acute Respiratory Failure with Hypoxia, Primary Insomnia, and Obstructive Sleep Apnea. Review of Resident #38's March 2023 Physician's Orders revealed an order that read: Home CPAP at hours of sleep and with naps. Review of Resident #38's Plan of Care revealed an intervention for Sleep Apnea: assist with CPAP equipment as needed. Review of Resident #38's eMAR (Electronic Medical Administration Record) revealed that he wore a CPAP nightly and with naps. On 03/20/2023 at 1:45 p.m., an observation was made of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to implement its process/policy for COVID-19 vaccination policy by failing to approve or deny an employee's request for COVID-19 vaccination exemption. Findings: Review of the facility's policy for COVID-19 vaccination policy titled Mandatory COVID-19 Vaccination/Booster Policy reads, in part, Determination of religious accommodation .The facility administrator will make an initial recommendation on accommodation, with final approval by facility ownership and/or corporate designee. Review of the facility's COVID-19 Staff COVID-19 Vaccination Status for Providers form revealed S13CNA (Certified Nurse Assistant) was listed as pending or granted non-medical exemption. Review of S13CNA Request Form for COVID-19 Vaccination Requirement revealed the date of request for religious exemption was 08/12/2022. Further review of the document revealed that the facility and S13CNA failed to complete the following question: Describe the religious belief or practice that necessitates this request for accommodation. No approval or denial was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.